Home Health & Hospice Week

Get ready to appeal when you spell a physician’s name wrong on the claim.

If you haven’t done your homework, PECOS edits hitting Jan. 6 will take a big bite out of your bottom line. And even the most well prepared agencies will pay in referrals they have to turn away.

Background:-In May 2010, the-Centers for Medicare & Medicaid Services-published an interim final rule based on the Affordable Care Act, requiring physicians who ordered home health and certain other services to be enrolled in PECOS with a valid National Provider Identifier (NPI) number for claims to be paid. CMS planned to begin editing for docs’ NPIs and PECOS information in January 2011. However, CMS postponed those edits indefinitely when physicians had inordinate difficulty enrolling in the system, among other problems.

In a final rule published in the April 27, 2012 Federal Register, CMS confirmed its plans to move ahead with the PECOS edits, then in early 2013 it set May 1 as the new deadline. Right before that date, CMS postponed the edits again.

Now: "Effective January 6, 2014, CMS will turn on the edits to deny Part B clinical laboratory and imaging, DME, and Part A HHA claims that fail the ordering/referring provider edits," the agency says in a newly revised MLN Matters article about the edits. Claims will deny when the "identification of the ordering/referring provider is missing, incomplete, or invalid, or … the ordering/referring provider is not eligible to order or refer," explains MLN Matters article SE1305.

Despite these edits’ history of delays, don’t bank on another postponement, experts caution. The delay earlier this year "was more about physicians, PAs and NPs getting their PECOS house in order," believes Lynn Olson, owner of billing company Astrid Medical Services in Corpus Christi, Texas. Now that docs have gotten their PECOS enrollment wrinkles smoothed out, expect to see CMS move full steam ahead with these edits required by the ACA.

Detail: The edits will apply to service dates, not claim submission dates, CMS explains in the article. Home health agency claims will be subject to the edits when "the statement ‘From’ date on the claim is on or after the date the phase 2 edits are turned on," the agency says.

Earlier This Year, PECOS Edits Would Have Denied 40% Of Claims

Many agencies are very prepared for these edits, experts allow. They instituted PECOS checking procedures before the last deadline and have kept up with them.

But many HHAs have not done their PE-COS edit homework and have failed to institute comprehensive procedures to combat related de-nials. "The number of denials is going to be shocking," predicts billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tenn.

When HHH Medicare Administrative Con-tractor CGS analyzed claims from September 2012 to February 2013, it found that about three-fourths of HHAs had filed claims during that period which would be denied by the new edits. HHH MAC Palmetto GBA found about 40 percent of HHAs filed claims that would fail the edits in just the January and February time period. The MACs have not released new figures to show whether agencies have improved those stats.

Like with face-to-face requirements, having agencies’ reimbursement hinge on actions required of the physician is frustrating to HHAs. The situation is "all messed up," laments Sharon Litwin with 5 Star Consultants in Camdenton, Mo.

And remember: Claims will be denied, not returned, under these edits. "I am convinced that agencies think their claims will be RTP’d (Returned to Provider - T Status), and they will be able to correct for a mismatch between their claim and the system when they did not spell the physician name exactly as it is in PECOS," Gaboury tells Eli. But something as simple as a name spelling discrepancy — using "Steven" instead of "Stephen," for example — "will result in a denial and the agency will have to file an appeal to get paid," Gaboury stresses.

One of the hardest changes required by these edits will be saying ‘no’ to referrals when the physician isn’t enrolled in PECOS. But agencies don’t have a choice. "If the agency does not turn down a referral when the physician — referring or certifying — is not in PECOS, then they will get a denial and not get paid," Gaboury says.

Note: The newly updated MLN Matters article is at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1305.pdf.